Malaria: The urgent need for a new prevention pact in Africa

In a few weeks, the rainy season will begin in many high burden malaria countries in Africa and young children will once again become exposed to malaria from the mosquitoes that gather in stagnant water when it rains. In 2023, the World Health Organisation (WHO) estimated that nearly 600 000 lives across Africa were lost to malaria. Four in every five deaths were in children under five years of age. With the unexpected severe cuts in malaria financing caused by changing US policy, we are very worried that many more young children will lose their lives to malaria in Africa. With the rains coming and prevention campaign planning already underway, time is running out for us to find alternative funding solutions.

Malaria is a preventable disease. In addition to bed nets and the new malaria vaccines, a key intervention used to protect young children from malaria is seasonal malaria chemoprevention (SMC). This intervention was recommended by the WHO in 2012 to reduce the escalating burden of malaria cases and deaths in countries where the greatest burden and transmission of malaria is seasonal. Two countries took on the challenge and piloted the intervention in 2012. Due to its incredible impact, 19 countries across Western, Central, Eastern and Southern Africa are now implementing SMC reaching over 54 million children annually*.

SMC has contributed to decreasing malaria cases to the extent where hospitals are no longer being overburdened with many malaria inpatients. SMC is also a relatively low-cost intervention – the full cost of getting 4 courses of SMC medicines, SP and AQ, to 1 child per year is between $4 and $6.30 depending on the country (and distances between communities, which vary from country to country). What is more, SMC has generated significant cost savings for families and health systems because they no longer need to buy malaria treatment, pay for hospital care or take time off work to look after sick children. A 2021 analysis in seven SMC implementing countries found that SMC saved health systems ~US$66 million and increased productivity by ~US$43 million. Given its immense economic impact and reach, a lapse in efforts, even for just one season could result in a significant increase in mala

ria cases, hospitalizations and deaths among children, and great loss to economic productivity for caregivers in implementing countries.

In 2018, all countries implementing SMC came together to form the SMC Alliance. The group meets every year to share best practices and to improve implementation of the intervention.

At our most recent annual meeting in Togo, the news of U.S. Government-funded malaria projects being terminated was at the forefront of discussions. Like the U.S., other donor countries are also considering funding cuts to address pressing regional security concerns. As such, countries that had started sharing plans to extend coverage to children over five years of age, or adding new districts, found themselves shifting to concerns about whether there would be enough funding for any campaign at all. How quickly could they find replacement funding for an intervention that has been proven to save the lives of the youngest children in some of the hardest environments of the world, particularly in the Sahel, where families live far from health facilities, and where governments struggle to retain health workers?

In other parts of Africa where the transmission of malaria is high all year round, there is an even more cost-effective intervention that could be deployed, which is called perennial malaria chemoprevention (PMC). Currently fewer than 4 million children out of the 35 million estimated eligible are reached with PMC. PMC involves giving a single drug, sulfadoxine-pyrimetheamine (SP), to healthy children under the age of two during age based scheduled visits to a health facility. This significantly reduces the human, financial, and logistical resources needed for PMC because rather than going door-to-door looking for children in their homes, which is how SMC campaigns work, caregivers bring their healthy children to the health facility at regular intervals for routine childhood vaccinations. Each of these health visits provides an opportunity for a health worker to offer SP to protect the child from malaria for a month. So, a child not only gets protected from childhood killer diseases by vaccination but is also protected from malaria. A course of 8 doses of SP costs between 20 to 50 cents per child to deliver because the health worker is already paid to be at the facility to administer vaccines, and the medicine is very cheap. PMC is relatively new and thus would have an initial introduction and scale-up cost of training health workers, but once they are trained and the intervention is integrated, the recurring costs are low.

Both interventions are critical as they protect children living in different geographic areas of countries (areas of seasonal and perennial malaria transmission), and countries prioritize strategies based on their resources and the needs of their population.

Many endemic country governments and philanthropic donors are trying to “save” the 2025 SMC campaigns across the Sahel. Planning and preparation for the campaigns are well underway with start dates for SMC less than one month away. Should the campaigns be missed, there will be an inevitable increase in malaria cases.

In Cameroon, PMC has been successfully institutionalized into the existing Essential Programme on Immunization (EPI) platform and scaled up across eligible areas in the country. Several other countries, including Benin, Côte d’Ivoire, and Mozambique have had similar success in introducing and scaling PMC. Country governments and philanthropic donors are similarly working together to sustain the intervention. We are confident that they will all succeed in their prevention efforts for 2025, but less sure about 2026 and beyond.

Across endemic countries, we have seen that using a suite of malaria prevention interventions – bed nets, SMC or PMC where relevant, vaccines, and insecticide sprays – altogether provide a greater level of protection than individual interventions. If children sleep under an insecticide treated bed net, 45% of malaria cases can be prevented. If they sleep under an insecticide treated net and receive SMC, 78% of malaria cases can be prevented. If they sleep under a net, receive SMC once a month for 4 months during the high transmission season, and get the new RTS,S malaria vaccine, then 92% of malaria cases can be prevented. This has been demonstrated by research trials in Mali and Burkina Faso. Therefore, to achieve the highest impact for both the health system and the economy, health ministries combine interventions and are increasingly using tailored approaches to optimize protection against malaria in the varied settings and at-risk communities across their countries.

This is not another article predicting catastrophe but one calling on national governments, the endemic countries private sector, and international donors to prioritize malaria prevention efforts to speed up the fight towards malaria elimination. The replenishment for the largest international donor for malaria, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, is coming up in October. In addition to immediate funding solutions, it is imperative that resources for the Global Fund are increased because for years, malaria elimination efforts have stalled due to limited resources. Now is the time for endemic countries to step up and re-invest efforts to help save more lives from malaria for years to come.

The most urgent and important goal is that children are protected from malaria, reducing sickness, saving lives, leading to reduced health costs for the health system and the patients, and supporting economic development. As the saying goes, prevention is better than cure. We must act collectively and invest in protecting children now for the 2025 malaria season and strive for the malaria-free future they deserve.